A one-year-old baby girl who died after a button battery became lodged in her oesophagus had been sent home from hospital on three occasions the fortnight before her death.
Isabella Rees died on February 4, 2015, three hours after her mother Allison found her "saturated" in her own blood, a Victorian coroner heard. When she arrived on that last occasion doctors sent her to be x-rayed, and the button battery was found.
She died from multiple cardiac arrests while she was on the operating table at Sunshine Hospital in Melbourne's St Albans, The Age reports.
The coroner heard the girl's family had first taken her to Sunshine Hospital's emergency department on January 16 because she was crying and vomiting. Her father says he told the hospital she had swallowed something - but this isn't reflected in the hospital records.
The baby was sent home after she stopped vomiting but two days later she was back with a fever.
The hospital gave her antibiotics and said she had a urinary tract infection. She also had parts of a broken water balloon in her stomach. On January 21 she finished her course of antibiotics and the hospital noted she was improving. She passed away two weeks later.
Isabella's heartbroken family have banded together since the baby's death and are fighting regulations around the batteries. They have also set up a Facebook page called Bella's Footprints - Button Battery Awareness.
In a tribute to Isabella after she died her family wrote "what we would give to have another chance to hear your voice, to feel your kiss and to see you grow. Our hearts are broken. We love you Bella."
Two years earlier a toddler died in Queensland after she had also swallowed a button-sized lithium battery.
Summer Steer, 4, died in June 2013 after swallowing a battery. Her symptoms were also wrongly diagnosed.
The coroner reviewed the similarities between the cases and must now decide if an inquest will be launched into Isabella's death.
In November 2015 Queensland Coroner John Hutton had found that Noosa Private Hospital's "initial limited investigation" of Summer's treatment before her death had been inadequate.